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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.secelid.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A rc t�- Ku 1 Sln U�-A c-) <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> t—tc,nTeC CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 0,5 T, CtVApklGnCe- TeS�lnc) T.nc- -76- "y p6l'ji-OwrA <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 9,0 , 130u <br /> CITY C4`GS STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Rep <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009-2012 $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$375/TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/ FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE _$375/FACILITY (use for piping, under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04/13/12 by KF) <br />